Wherein a surgeon tells some stories, shares some thoughts, and occasionally shoots off his mouth. Like a surgeon.

Friday, May 23, 2008

Uh Oh...

Another item from the American College of Surgeons:

COLLEGE OPPOSES RECOMMENDATION TO INCREASE PAYMENT TO PRIMARY CARE

On Friday, May 16, the American College of Surgeons and 13 surgical specialty societies sent a letter expressing strong opposition to a Medicare Payment Advisory Commission (MedPAC) recommendation, which calls for increasing payments to primary care physicians, while cutting reimbursement for all other physician services. The payment reductions for other physician services, including major surgical procedures, would occur because the pay hike for primary care must be budget-neutral. Only two of the 17 MedPAC Commissioners....opposed the recommendation. In their correspondence to MedPAC Chair Glenn Hackbarth, JD, the College and the other surgical societies noted that primary care is not the only specialty experiencing significant challenges in today’s health care environment. The letter cites several difficulties facing surgery, including decreased reimbursement, surgical workforce shortages, and increased practice expenses, especially for professional liability. Copies were sent to leading congressional committees with jurisdiction over Medicare policy. The letter concludes by noting that “[if] this recommendation is acted upon, the ones who stand to lose the most are not America’s surgeons but rather the patients who rely on the life-saving care that only surgeons can provide.” [Interesting side note: the Chair of the P.A.C. is a JD, ie, a lawyer!]

I've been known to say, when my clinic and the non-clinic docs in town were even more acrimoniously at war than they now seem to be, that the insurance companies must love it: set us upon ourselves, grabbing at whatever is offered lest the other side make an even less-favorable but exclusive deal. This sort of thing will get worse before it gets better. If it gets better. Which it won't.

It's amazing, isn't it? In our lifetimes -- who'da thunk it? -- we're actually going to see cataclysm: events are moving so fast, we're living in the time of the passing of the tipping point on oil, on the federal budget crisis, and we'll bear witness to the collapse of health care in the US. And there's a good chance that in my dying breath, as we rise up as a nation and begin killing one another, I'll be able to say, recalling the pivotal 2008 election which turned on race and religion and spouses and fear of the dark instead of on energy and budgets (and infrastructure, and health care, and environment....), "I TOLD YOU SOOOOOOO00000oooooooooooooooooo......."

I have that same feeling in the pit of my stomach. Reading this kind of statement makes me angry. Everyone is protecting their own slice of the pie, but nobody is doing what is good for the industry itself. I guess the ACS does not believe that a lack of primary care docs is a crisis. Perhaps it isn't.

I do wonder if any politician can have the political nerve to face the screams of the special interests groups that will be at their door with torches, no matter what choice they make. I suspect we will see a collapse or a total crisis before much will get done. People were driving SUV's up until very recently. People wait until the last minute before doing substantive changes

anonymous: I'd say it depends on how universal health care is structured. The term, per se, doesn't imply a particular process. The larger problem is the ongoing sense that we can get everything for nothing, that taxes equal treason, that deficits and borrowing money from China and Saudi Arabia aren't a problem. Until we're willing to decide what we can and want to pay for health care this sort of thing will continue. Which means it will always continue, all the way down to dissolution of the whole system.

Maybe it's better this way. Primary docs will *have* to go non-participating with Medicare, but are potentially affordable to patients ($50 office visit, anyone?) but patients can use their Medicare when they need a (orders of magnitude)more costly surgery.

Still, I am saddened by the "damn zero-sum mindset". We are supposed to be on the same team, people! Think Heroes, not Survivor!

If Docs were all paid fairly then maybe they wouldn't constantly be trying to increase there income by putting imaging in their offices, hiring Physician extenders to see patients etc etc.

The Internist want to take money from everyone else because they are underpaid (which they are). Please don't forget that many of the Specialists of the world went through 3-4 MORE years after medical school than a PCP. Shouldn't this be worth something?

If there is one group that is more screwed by the current system than PCPs (and there is), it's general surgeons. Cutting their salaries further is just absolutely brutal. And stupid. You can walmartize primary care with as many so-called "extenders" as you want, but WTF are you going to do when there are no general surgeons for your toasty appendix?

I think the problem is that people are going to have to accept that medicine and basically everything else is now a zero sum game. America is in real trouble on many fronts. Last year we imported 4,905,234,000 barrels of oil(Data from US Dof Energy). At current prices $130/barrel, we will be spending about $800Billion on oil this year(Talk about funding both sides of the war on terror). The energy we gain from it disappears upon its use and those foreign owned dollars will be used by oil producers to fund their growth(and if we are lucky buy up US assets to maintain our standard of living. Heaven help us if they decide to stop buying T-bills).

As for the medical climate, it’s currently a three group system in my eyes. 1) The Haves--Those doing cosmetic procedures who are paid what the market deems fair for its services(Derm Plastics Ophtho). This groups income is based solely on Americas desire to appear Fantastic and because we are a very superficial culture, people will continue to take out mortgages to pay for their servuces. 2) The kinda-haves--These are procedural based specialists who 15 years ago were able to convince a committee that their services and CPT codes should be rewarded. This group includes radiology cardiology urology gastroenterology and basically anyone who can find a fiber-optic scope to place in an orifice. And 3)The HAVENOTs this group includes all providers who attempt to make their living by E+M codes and General Surgeons.

Group 1 will be fine so long as disposable income in the top 10% bracket is available. Currently an ever shrinking pie is being fought over by Groups 2 and 3. Group 2 is winning because the system is currently in their favor. And Group 3 does whatever they can to get into group 2(IE add imaging to their clinic which initiates more animosity through turf wars). This battle will last until medicare is truly faced with the decision of hacking off limbs to keep above water(by this I mean the financial picture becomes bleak enough that real cuts not just a lack of reimbursement increases occurs). I do not know when this will occur but 10%+ medical inflation annually makes this a near certainty.

As lay people generally seem reluctant but still willing to see NPs and PAs it is my strong guess that these extenders will take over insurance and medicare funded primary care and continue to drive down labor costs in the affected fields. The concierge model of primary care will probably become the only one in which current primary docs will be able to make a sufficient living. It is ludicrous that people do not see the value in primary care, but it is my naïve medical student opinion that most people perceive the world in this way/

The perception of surgeons and specialists in this country is slightly different. Patients want surgeons operating on them and cardiologists catheterizing them. Patients may fly ot India to have a procedure done more cheaply, but they will always want a doctor to perform it. PAs need not apply for these positions. As such these fields have slightly firmer ground to stand on from a public perception and necessity stand point. Currently the general surgeons are getting shafted by comparison to other surgical specialties but as another commentator pointed out, someone is going to have to operate on that “surgical abdomen.” As the population ages it will be when medicare cuts reimbursement to the point that these specialists stop taking medicare patients and the average AARP member is unable to get specialist care that the revolt will occur. Remember in not too long seniors wanting government subsidized care will be the controlling voting pool of the electorate.

It is a sad state of affairs but how I choose my specialty is strongly affected by the basic premises listed above. I enjoy many parts of medicine but I cannot see the political climate and the financial climate altering in such a way as to pick a career in something the public deems a PA or NP can do. As such I am staying out of Group 3(except for possibly general surgery whose prospects will go up as their numbers dwindle). Although many other medical students have probably not thought about it in the ways I have described, their actions speak volumes. The following is a link to the match data for 4th year medical students. http://www.nrmp.org/data/matchoutcomes2006.pdf Look at page 10 which shows boards scores for various specialties. (I wonder why the trend line looks the way it does?(sarcasm)

These turf wars are only just beginning.Sorry for the long rant

And to the last poster... Certain specialties make multiples of what pediatricians make. This discrepancy is the issue at hand. Its a fluid dynamic, but to say Doctors are renumerated well is to broad. Plastic surgeons, orthopedists not taking medicare, urologist to name a few are doing quite well currently. The problem lies in primary care and other evaluation and management specialties that cannot charge for procedures. They make quite a bit less(Multiples less).

Chris Bent: a thoughtful and well-reasoned comment which, I think, is very accurate. Thanks.

Anonymous (the money questioner): it's all relative, isn't it? Time will answer your question. If enough people of high quality are willing to work as hard as most doctors need to work to get there, and to do their jobs, then (fill in blank in dollars) is enough. If not, well, then, society will have to decide: will it settle for less dedicated doctors, less competent ones, de-facto (or maybe actual) rationing because there aren't enough in a given specialty? Or will it address the ever-falling compensation issue? We'll see.

Meanwhile, it doesn't look good. Not for that, nor for fixing infrastructure, nor education.... you name it. We're broke as a nation. In more ways than one.

Good point that I had forgotten to mention. How many other professionals give up their 20's and work for 3-5 yrs for minimum wage(residency)? I will have spent just under 200K in medical school. Furthermore, I will be over 5 years behind in my IRA/401K. Compounding hurts doctors in training/recent grads on both ends. Loans add interest and we lose out on the interest we could have collected had we gone out and worked immediately out of school. My girlfriend graduated the same year I did and is a chem. engineer making very good money right out of undergrad. She can sop away a lot into the stock market or other that I just don't have.

I guess the question for the poster is, is 200K enough considering Age 23-27 are lost spending 50K annually. And then making 40K annually as a resident working 80 hours per week from ages 28 to 31-33). For smart bright twenty-two year olds making the decision to enter medical school or get a reasonable job(IE 60k+ out of undergraduate) going into a specialty is the only way it can make financial sense in the current environment. Remember 200K is an average and pediatricians and other PCPs are on the lower end of that bell curve. If you want physicians to stop acting like children asking for more money, the system is going to have to once again compensate them according to their education and abilities. Then your doctor will stop looking for marginally beneficial lab tests to perform on you so that he can actually make a living(Ok this is a little over the top but it almost certainly occurs). The 30 min office visit after costs nets your PCP $10-20 if he's lucky.

Credible and productive PhD programs at least pay for students to get their degrees.

About Me

I'm a mostly retired general surgeon. With my surgical blog, my intention is to inform, entertain, and possibly educate the reader about surgery, and about the life and loves of a surgeon: this one, anyway. Don't know what I'm thinking, doing a political blog, too.
In an amazing coincidence, I've also written a book, "Cutting Remarks; Insights and Recollections of a Surgeon." It's about my surgical training in San Francisco in the 1970s, aimed at the lay reader with the goal of entertaining with good stories, informing with understandable details of surgical anatomy, procedures, and diseases. Knowing you, I bet you'd enjoy it. In fact, if you like Surgeonsblog, you'll absolutely love the book!

Boring, Unoriginal, but Important Disclaimer:

What I say here is as true as I can make it, based on my experience as a surgeon. Still, in no way is it intended as specific medical advice for any condition. For that, you need to consult your own doctors, who actually know you. I hope you'll find things of interest and amusement here; maybe useful information. But please, please, PLEASE understand: this blog ought not be used in any way to provide the reader with ideas about diagnosis or treatment of any symptoms or disease. Also, as you'd expect, when I describe patients, I've changed many personal details: age, sex, occupation -- enough to make them into no one you might actually know. Thanks, and enjoy the blog.